Purim Party

THURSDAY EVENING - PURIM FEAST RESERVATION FORM

Family Name: 

First Names:       

Address:  
City:         State:  
Zip Code: 

Phone:   
E-mail: 

Adults   00   01   02   03   04   05   06   07   08   09   10     Children   00   01   02   03   04   05   06   07   08   09   10       
  

Cost:  (with advance reservations)                                   
            $36 per Adult   $18 per Child     

  I would like to be an event sponsor ($360.00) 

Please charge a total of $ to my credit card.

Credit Card Type:   Visa   Master Card   American Express  

Credit Card Number:    

Exp.(mm/yyyy)   01   02   03   04   05   06   07   08   09   10   11   12   /   2016   2017   2018   2019   2020   2021   2022  

My check payable to Chabad of Parkland is in the mail.